Provider Demographics
NPI:1992910301
Name:JOHNSON, CRAIG M (DO)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-298-7371
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:6535 NEMOURS PARKWAY
Practice Address - Street 2:NCH
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:33282-7884
Practice Address - Country:US
Practice Address - Phone:407-567-4000
Practice Address - Fax:407-567-5924
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC200101192085P0229X
WI535052085P0229X
MA2354912085P0229X
FLOS117892085R0204X, 2085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006252800Medicaid